Steven R. Wells

Placental apoptosis in preeclampsia.

Objective To determine whether preeclampsia is associated with an increase in placental apoptosis and differential expression of mediators of apoptosis. Methods Placental samples from 31 preeclamptic women and 31 normotensive controls were analyzed using terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick-end labeling staining. Expression of Fas, Fas ligand, Bcl-2, and Bax was assessed using immunohistochemistry. Results The median percent apoptotic nuclei was significantly higher for the study group than for the controls (0.49 versus 0.19; P = .001), as was the median percent apoptotic nuclei in the trophoblast nuclei (0.33 versus 0.09; P < .01). Fas ligand expression was significantly less and Fas expression significantly greater in the villus trophoblast among the study subjects compared with controls. There was no difference in the expression of Bax or Bcl-2 between groups. Conclusion Placental apoptosis and altered expression of Fas and Fas ligand in trophoblast might influence pathogenesis or sequelae of preeclampsia.

Complementary and alternative medicine in pregnancy: a survey of North Carolina certified nurse-midwives

Objective To determine the prevalence and types of complementary and alternative medicine therapies used by certified nurse-midwives in North Carolina. Methods Surveys were sent to all 120 licensed certified nurse-midwives in North Carolina requesting information concerning their recommendations for use of complementary and alternative medicine for their pregnant or postpartum patients. Results Eighty-two responses were received (68.3%). Seventy-seven (93.9%) reported recommending complementary and alternative medicine to their pregnant patients in the past year. Forty-seven (57.3%) reported recommending complementary and alternative medicine to more than 10% of patients. The percentage of nurse-midwives who recommended each type of complementary and alternative medicine was as follows: herbal therapy (73.2%), massage therapy (67.1%), chiropractic (57.3%), acupressure (52.4%), mind-body interventions (48.8%), aromatherapy (32.9%), homeopathy (30.5%), spiritual healing (23.2%), acupuncture (19.5%), and bioelectric or magnetic applications (14.6%). The 60 respondents who reported prescribing herbal therapies gave them for the following indications: nausea and vomiting, labor stimulation, perineal discomfort, lactation disorders, postpartum depression, preterm labor, postpartum hemorrhage, labor analgesia, and malpresentation. Conclusion Complementary and alternative medicine, especially herbal therapy, is commonly prescribed to pregnant women by nurse-midwives in North Carolina.

PERIPARTUM CARDIOMYOPATHY : A REVIEW OF THE LITERATURE

UNLABELLED Peripartum cardiomyopathy (PPCM) is a poorly characterized, rare form of cardiomyopathy. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The presentation is similar to other forms of congestive heart failure; the diagnosis of PPCM should not be considered until other causes of cardiac dysfunction are ruled out. Echocardiography is central to diagnosis. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Intensivists and anesthesiologists should be consulted to assist with management in complicated cases. Management of PPCM is essentially supportive. Prognosis is poor, although cardiac transplant is improving prognosis and should be considered when conventional therapy fails. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES After completion of this article, the reader will be able to understand the typical presentation of peripartum cardiomyopathy including adverse outcome predictors, to understand how to make the diagnosis of PPCM and how to manage it, and to understand the natural history of the disease.

First-trimester diagnosis of placenta previa percreta by magnetic resonance imaging

Placenta previa percreta with bladder involvement is a rare but devastating complication of pregnancy. Antepartum diagnosis of this serious condition allows the obstetrician to alter his or her management of abdominal delivery and minimize the magnitude of bleeding. We report a case in which magnetic resonance imaging was able to detect placenta percreta in the first trimester. If further research demonstrates usefulness of this diagnostic modality, magnetic resonance imaging may prove to be useful in caring for patients with this condition.

Analysis of the risks associated with calcium channel blockade: Implications for the obstetrician-gynecologist

Calcium channel antagonists are widely prescribed in obstetrics and gynecology for blood pressure control and tocolysis. Concerns have recently arisen regarding the safety of these agents. Several studies found that short-acting forms of calcium channel blockers were associated with increased cardiovascular mortality, malignancy, and gastrointestinal bleeding. A recent meta-analysis found a significant increase in the risk of mortality in patients treated with a short-acting form of nifedipine. Another subgroup analysis of an observational study of older hypertensive patients found a significantly increased risk of cancer and gastrointestinal hemorrhage in patients prescribed calcium channel blockers. Both in vitro and small human in vitro series have reported a potential for cardiac toxicity in pregnant women treated concomitantly with calcium channel blockers and magnesium sulfate. Until additional data are available, we suggest that when calcium channel blockers are used in obstetrics and gynecology, the long-acting variety be prescribed. Concurrent use of calcium channel blockers and magnesium sulfate should be undertaken cautiously because of the potential for synergistic depression of cardiac function.

Pharmacologic treatment of psychiatric disease in pregnancy and lactation : Fetal and neonatal effects

Objective To review published data pertaining to safety of psychoactive drugs used to treat psychiatric disorders during pregnancy and lactation. Data Sources A computerized search of articles published through July 1995 was performed on the MEDLINE data base. Additional sources were identified through cross-referencing. Methods of Study Selection All identified references were reviewed with particular attention given to study design. Data Extraction and Synthesis Each reference was reviewed to determine the safety of psychoactive agents to treat depression, bipolar disease, schizophrenia, and anxiety during pregnancy and lactation. Prospective or large retrospective studies were given more importance than case reports. Conclusion Psychoactive medications may be used during pregnancy. Because data on safety are largely retrospective, treatment decisions must be weighed carefully.

Ovarian suspension in massive ovarian edema

Massive ovarian edema is an uncommon condition found in young women that is speculated to occur as a result of incomplete ovarian torsion. We present the second patient to our knowledge to undergo ovarian suspension as a treatment for this condition. This approach succeeded after ovarian wedge resection had failed. Our patient remained symptom-free at 1 year of follow-up. Ovarian suspension should be considered when this pathologic entity is diagnosed.

Cesarean delivery for fetal malformations.

We reviewed existing data on fetal abnormalities to provide guidelines to determine which conditions have an improved neonatal outcome by cesarean delivery. We used Medline database to search for English language papers on a variety of fetal conditions that could influence the mode of delivery. We reviewed these sources with particular attention to how the mode of delivery influenced neonatal outcome. Conflicting data exist regarding optimal mode of delivery for many fetal conditions. Cesarean delivery may improve neonatal outcome for fetuses with isolated meningomyelocele, hydrocephalus with concomitant macrocephaly, anterior wall defects with extracorporeal liver, sacrococcygeal teratomas, hydrops, and alloimmune thrombocytopenia with low platelet count at term. Hydrocephalus without macrocephaly, anterior wall defects without an extracorporeal liver, ovarian cysts, skeletal dysplasias, fetuses whose mothers have immune thrombocytopenic puer-pura and fetuses with alloimmune thrombocytopenia with acceptable platelet counts may safely be delivered vaginally.

Diagnostic value of cervical fetal fibronectin in detecting extrauterine pregnancy

OBJECTIVE To determine whether fetal fibronectin (FFN) might serve as a marker to distinguish intrauterine versus extrauterine pregnancy. DESIGN Prospective cohort study. SETTING Academic research center. PATIENT(S) Cervicovaginal FFN samples were obtained from 46 women who were at high risk for or presented with signs and/or symptoms of extrauterine pregnancy. INTERVENTION(S) Samples of blood were analyzed for FFN with use of an enzyme-linked immunoabsorbent assay (ELISA). MAIN OUTCOME MEASURE(S) Fetal fibronectin level. RESULT(S) The rate of extrauterine pregnancy in our study was 26.1%, with 12 extrauterine and 34 intrauterine pregnancies identified by ultrasonography or at time of surgery. Seventeen samples had FFN levels of > 50 ng/mL and were considered positive (range, 0-1,000 ng/mL). Positive FFN levels were observed in 41.7% (5 of 12) of women with extrauterine pregnancies versus 35.3%) (12 of 34) of women with intrauterine pregnancies. The sensitivity, specificity, and positive and negative predictive values for extrauterine pregnancy were 41.7%, 64.7%, 29.4%, and 75.9%, respectively. CONCLUSION(S) The use of FFN does not appear to alter significantly the likelihood of identifying extrauterine pregnancy over current laboratory or ultrasonographic methods.

Integrity, Abortion, and the Pro-Life Perinatologist

In a response to a previous article on the contemporary practice of perinatal medicine by physicians with prolife world views the authors agree that invasive prenatal diagnostic procedures may challenge the integrity of prolife physicians because in most cases the risk of an abnormality is equal to the risk of the loss of a normal pregnancy. However it is the physicians duty to inform the patient about the procedures and the patients right to decide on her care. The authors find no conflict in prolife physicians providing factual information about available antenatal diagnostic procedures and therapeutic options or in prolife physicians simultaneously presenting their own world views to the patient. They believe that prolife perinatologists should not be excluded from patient care because such exclusion would eliminate the proponents of a valid argument and silencing dissenting opinion limits patient autonomy. The disagreement between prolife and prochoice physicians is really over what is justifiable and what requires compromise. For example very few prolife physicians would hesitate to end an ectopic pregnancy and prochoice physicians may express reservations to patients who wish to know the sex of their fetus in order to decide whether or not to have an abortion. The practice of perinatology requires careful clarification of the physicians concepts of maternal and fetal rights and if a physician with prolife convictions is unable to present both viewpoints to a patient then it probably would be better for that physician to enter another specialty.